As many as 72 million surgical procedures are performed in the United States each year. For every one of these procedures, information about the diagnoses, treatment and relevant procedure documentation must be captured. A major problem in this information capture is that different entities need the same data but they capture the data in different ways and at different times due to a disjointed health care information structure with no one master.
Before a physician performs surgery in a hospital or outpatient clinic, basic information about the procedure is captured first for the hospitals (or clinics) operating room/suite system. This is usually done in an analog manner via telephone. This data, collected by the MD's office, is needed for the hospital to plan the procedure, but it is not generated in a consistent, standard, or legible fashion. Once an Operative Event has been completed the physician or her/his assistant completes dictation into a tape bank that will later be transcribed into an operative note. To be maximally useful, these notes should be transcribed and added to the patients' record immediately. However, it is common for the “draft” note to be outstanding for five or more days. Thus, it is uncommon for a hospitalized patient to have a real and/or complete Operative (event) Note in their chart during the hospital stay. Accordingly, the JCAHO (Joint Commission for Accreditation of Healthcare Organizations) requires that some minimal information be “Hand Written” in to the hospital chart. Once the note is transcribed, it is added to the patients' record, but it is not “official” until the physician who performed the operation reads the operative note and corrects any errors. About 20-40% of these initial operative notes need changes. Once the operative note is corrected and signed by the physician, the “draft” note is removed from the patients' medical record and replaced with the signed operative note. Separately, getting the notes to and from the physician is a significant problem for hospital medical records departments and for the physicians/physician offices. Not surprisingly, a percentage of operative notes go missing-in-action. These MIA notes are a large portion of the hospital's focus when it is required to complete an audit of its system by the JCAHO every three years. Most importantly, the lack of timely availability of an accurate operative note for the use of involved parties, leads to billing delays and errors causing payment delays, denials, and reductions to all interested parties.
It is a universal requirement that a record of surgery be created. This record is created for three purposes:    1. To comply with facility/governmental requirements;    2. To provide documentation of procedure completion for insurers; and    3. To facilitate future or current disease/procedure specific research.
Physicians using current analog/dictation methods do not routinely consult the coding texts which their office-clinic and the hospitals billing department use to numerically describe to the insurers the procedures and diagnosis for a given patient. Consequently, operative/procedure notes do not always match the codes that should be used to describe a specific event. Additionally, current dictation methods do not assist a single and certainly not a group of physicians to describe a procedure(s) in a consistent/reproducible fashion. Of additional importance, more than one group (Hospital, Proceduralist, Anesthesiologist, Pathologist, Radiologist) is often coding the same event independently. This creates more than a little confusion for the insurer looking at a bill for a particular patient who received treatment from three or more distinct entities, for example the 1) hospital, 2) anesthesiologist, 3) pathologist, and 4) surgeon, all on the same day which by report is for varying diagnosis with varying treatments. Variations in dictation combined with coding variations can also result in wide variations in how the physician is paid by insurance companies. Finally, because the current data is inconsistent, not a database, and not readily available to the physicians, it cannot be used by the physician to improve care, facilitate marketing, or enhance re-licensing usage without separate time consuming data entry.
There are a number of systems in the marketplace that allow for the entry of procedure information. These systems range from low cost Palm Pilot based systems to online billing systems. These systems have several major flaws. The Palm based systems are expecting the physician to significantly change their behavior in order utilize their software. They are complex and cumbersome to use and provide little value to the physician, other than a portable subset of the patients' record. These systems do not integrate into existing systems and other than early adopter “geek doctors”, have not succeeded in the market. The existing billing systems are designed as accounting first and an easy way to input procedure information last or not at all. Billing systems are also different between the hospital and the doctors' offices, thus information is consistent only by random luck.
Accordingly, there is considerable room for improvement in the area of operative event documentation and the storage and use of the associated data.